Primary event is glomurus basement membrane (GBM) damageprogressive thickening of the GBM due to formation of advanced glycosylation end products (AGEs)passage of macromolecules through the GBM may activate inflammatory pathways (Evans & Capell, 2000) (cross section) Objectives Pathophysiology Diabetic Nephropathy Juanita has been observed by her nephrologist for the past several years for manifestations of progressive chronic kidney disease. Assess kidney functionglomerular filtration rate blood creatinine proteinuria

(Evans & Capell, 2000) Diagnosis All of Juanita’s subjective and objective data indicate her need for dialysis. As her kidneys cannot filter her blood, the excess accumulation of fluid and waste products has reached toxic levels. Juanita’s symptoms and signs are getting progressively worse; starting her on hemodialysis is vital to her overall wellness, and life.

Eight weeks ago she had an arteriovenous fistula created in preparation for starting hemodialysis. Treatment to replace the work of her non-functioning kidneys Blood is removed from the body to remove waste and excess fluid. The clean blood is then returned into the body via an arteriovenous fistula.Done by connecting an artery directly to a vein. Due to the increased blood flow, the vein grows larger and stronger, making repeated needle insertions for hemodialysis treatments easier. Two needles will then be inserted into the fistula to cycle the blood.

Interventions:Monitor hemoglobin levels as an indicator of the client's oxygen-carrying capacityMonitor response of hemoglobin to ESA's (erythropoiesis-stimulating agents)Administer oral iron between meals, IV iron and ESA's to maintain erythropoiesis and stimulate production of RBC'sAdminister folic acid after hemodialysis because it is removed with dialysisProvide adequate periods of rest to enable client to recuperate from past activities and participate in future activitiesTeach client to plan activities to avoid fatigue (Nurko,2006)

Interventions:Listen to the concerns of the client to convey a caring attitude and foster a relationship to determine how client is handling the situationAllow client time to mourn loss of body function so that client can deal with feelings and identify ways of coping with losses more effectivelyInclude family members in discussions of client's concerns to enable them to assist the client and foster their support and understanding (Lewis et al, 2010). Prophylactic infusion of normal saline. If the patient loses too much blood volume, they can suffer from extreme hypotension.

Hemodialysis patients must follow a strict diet and are only allowed approximately 250-500 mL of fluid per day, as too much fluid and waste problems can accumulate in the blood and cause serious wellness issues. Most renal failure patients undergo hemodialysis treatment 3-4 times a week. The session takes approximately 4-5 hours

Figure 1: Arteriovenous fistula. (National Kidney and Urologic Diseases Information Clearinghouse, 2011) References: Summary Over the past week, Juanita has experienced anorexia, nausea, vomiting, problems with concentration, and pruritis. Juanita has also complained of swelling in her hands and feet, weight gain of 10lb (4.5kg) in the past 2 weeks, and dyspnea and weakness when walking. Anorexia, Nausea, and Vomiting: buildup of toxins in the body; irritation of the GI tract